Sanfey H, Haussman G, Isaacs I, Ishitani M, Lobo P, McCullough C, Pruett T
Transplant Division, University of Virginia Health Sciences Center, Charlottesville 22908, USA.
Clin Transplant. 1997 Oct;11(5 Pt 2):500-4.
The long-term side effects of lifelong steroid immunosuppression are well documented, therefore, steroid withdrawal (SW) if safe would clearly be of benefit. From 1987-1996, 470 kidney transplants were performed at our institution. During this time period, steroid withdrawal was offered to a select group of patients (n = 43) who were at least 1 year post transplant (27.6 +/- 12.0 months, 15-64 months), had stable graft function and had experienced only mild episodes of rejection in the postoperative period. Informed consent was obtained from all participants. Twenty-five patients were male and 18 were female. The mean age at time of transplantation was 42.4 +/- 14.1 years (17-65 years). There were 28 cadaveric renal transplants (CRT), 10 living related kidney transplants (LRT) and 5 simultaneous kidney-pancreas transplants (SPK). Maintenance immunosuppression in all patients consisted of CSA 3-5 mg/kg, and AZA 1-2 mg/kg. Twenty-nine patients (67%) have remained off steroids with good renal function for 13-59 months (38.3 +/- 11.0). Steroids were restarted in 14/43 (32%) patients 1-36 months post SW (13.3 +/- 11.0 months). Eight of these 14 patients had a rise in creatinine and biopsy proven rejection, 5 of whom responded to reinstitution of steroid immunosuppression, and have stable renal function (CR = 2.0 +/- 0.4) 41-53 months (45 +/- 4.0 months) post SW. Three (7%) patients lost their allograft. One was a SPK recipient who retained good pancreatic function and subsequently received a successful 2nd kidney transplant. The other 2 patients died awaiting retransplantation. Steroids were recommenced in 6/14 patients who did not develop rejection for inability to tolerate CSA/AZA (2), anxiety (2) or recurrent disease (2). In the majority of our patients, (93%) SW did not result in immunologic graft loss. A graft loss of 7% (3) is not significantly different from the expected graft loss in a kidney transplant recipient population over a time period of 9 years. Therefore, we feel that with careful monitoring steroid withdrawal can be safely accomplished in select patients.
终身使用类固醇免疫抑制的长期副作用已有充分记录，因此，如果安全的话，停用类固醇（SW）显然会有益处。1987年至1996年期间，我们机构进行了470例肾移植手术。在此期间，对一组特定的患者（n = 43）提供了停用类固醇的方案，这些患者移植后至少1年（27.6 +/- 12.0个月，15 - 64个月），移植肾功能稳定，且术后仅经历过轻度排斥反应。所有参与者均获得了知情同意。25例患者为男性，18例为女性。移植时的平均年龄为42.4 +/- 14.1岁（17 - 65岁）。其中有28例尸体肾移植（CRT），10例亲属活体肾移植（LRT）和5例同期肾 - 胰联合移植（SPK）。所有患者的维持免疫抑制方案包括环孢素A（CSA）3 - 5 mg/kg和硫唑嘌呤（AZA）1 - 2 mg/kg。29例患者（67%）停用类固醇后肾功能良好，时间为13 - 59个月（38.3 +/- 11.0）。14/43（32%）例患者在停用类固醇后1 - 36个月（13.3 +/- 11.0个月）重新开始使用类固醇。这14例患者中有8例肌酐升高且活检证实有排斥反应，其中5例对重新使用类固醇免疫抑制有反应，停用类固醇后41 - 53个月（45 +/- 4.0个月）肾功能稳定（肌酐清除率 = 2.0 +/- 0.4）。3例（7%）患者移植肾失功。1例是同期肾 - 胰联合移植受者，胰腺功能良好，随后成功接受了第二次肾移植。另外2例患者在等待再次移植时死亡。6/14例未发生排斥反应的患者因无法耐受环孢素A/硫唑嘌呤（2例）、焦虑（2例）或疾病复发（2例）而重新开始使用类固醇。在我们的大多数患者中（93%），停用类固醇并未导致免疫性移植肾失功。7%（3例）的移植肾失功率与肾移植受者群体在9年时间内预期的移植肾失功率无显著差异。因此，我们认为通过仔细监测，在特定患者中可以安全地完成停用类固醇。
